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There’s No Algorithm For Empathy

2020; Project HOPE; Volume: 39; Issue: 2 Linguagem: Inglês

10.1377/hlthaff.2019.00571

2694-233X

Hannah Wild,

Education and Critical Thinking Development

Narrative MattersPatient-Centered Care Health AffairsVol. 39, No. 2: Opioids, Investing In Social Determinants & More There’s No Algorithm For EmpathyHannah B. Wild Affiliations Hannah B. Wild ([email protected]) is a fourth-year MD candidate at Stanford University School of Medicine, in California.PUBLISHED:February 2020Free Accesshttps://doi.org/10.1377/hlthaff.2019.00571AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits AbstractWhen physicians rely on a behavioral “recipe” to convey empathy, patient care can suffer.TOPICSCancerMedical educationPatient careEducationCommunicationsBiopsyControlled trialsMedical malpracticePhysician-patient relationshipNarrative matters Illustration by Brett RyderMy cancer was boring to me at first. There was an expectation that it would be bound up in my identity, but I found it about as defining as a flat tire. I was a senior in college, ravenous for the world around me. I had just been awarded a fellowship to study the traditional medical practices of nomadic herders in East Africa. My desire for raw experience burned white-hot. My letters from this era read like hieroglyphics—I could barely express myself, choking on my own sense of intensity. The last thing I found interesting was the lump I had been ignoring for the past semester. At the oncologist’s office, I developed an aesthetic fascination with tumor histology much as I had with lichen acid’s role on mineral dissolution in the pages of my organic chemistry textbooks. Otherwise, I had no patience for my disease. The news that I would have to sit still to wait for biopsies and treatment inflamed my sense of urgency. I was like a fighting dog with cayenne in its eyes, straining at the leash.So when doctors approached dripping in sympathy, it was as if they were offering overwrought condolences about a delay in an alternator repair that stood between me and the open road. I was not surprised that they “could not imagine how hard this was” for me. They had never asked, and they knew nothing about me. I did not have the energy to fend off canned responses to their imagined version of my feelings when (a) I myself did not know how I felt, and (b) feelings were at the bottom of my priority list. I wanted to fix the issue as fast as possible and head to the field. Empathy was not what I needed. I wanted competence, confidence, and authenticity. At that time, I preferred the humorless, emotionally obtuse doctors who unflinchingly rattled off Kaplan-Meier curves and cited New England Journal of Medicine articles on the uselessness of my only chemotherapy option to the new school of empathy acolytes. Another patient would have needed something different. One size does not fit all.Five years after my cancer diagnosis, I matriculated in medical school. During two years of preclinical education, medical students are subjected to a slew of didactic trainings intended to teach empathetic behavior. Diagrams, protocols, frameworks, and algorithms accompany these sessions. An academic industry has grown up around empathy in medical education, including validated scales and randomized controlled trials that provide support for such assertions as, “Empathy is a cognitive attribute” (attributed to Mohammadreza Hojat, who developed the Jefferson Scale of Empathy). This initiative is motivated partly by data showing that malpractice suits are associated with patients’ perception of physician communication, along with the move to tie incentives such as Medicaid reimbursements to patient satisfaction. The movement has spawned corporate purveyors such as Empathetics, a company that purports to reduce the likelihood of malpractice claims with the trademarked acronym E.M.P.A.T.H.Y. (for eye contact, muscles of facial expression, posture, affect, tone of voice, hearing the whole patient, and your response). Despite good intentions, these didactics come across as if medical professionals are merely engaging in a higher-stakes version of Mr. Potato Head: open up the Tater Tush, select one part per hole, and voilà—you have produced an empathetic interaction.Acute bacterial sinusitis? Amoxicillin plus clavulanate. Death of a family member? Concerned manipulation of eye muscles, statement of condolence, plus 10 mg/grief-kilograms of compassion. Considering a patient’s experience of their illness is fundamental, but it cannot be accomplished with recipes. While it may be possible to teach students to communicate in a manner that is perceived as empathetic, is it possible to teach students to feel empathy—which is an inner experience rather than an outer act?I still sting with resentment toward one young doctor who followed all the “right” scripts at my expense during my cancer treatment. We met one morning at an East Coast teaching hospital, one day after an inguinal lymphadenectomy to remove the lymph node basin into which the tumor drained. As she hesitated in the doorway wearing a chartreuse cardigan and a labored expression of concern, I already felt besieged. I’m particular about positioning. I don’t like my exits blocked, and I don’t like being in a recumbent position in the presence of others. She watched me struggle to sit up without intervening. My unwashed hair stuck together in a matted clump like a limp opossum. A mesh-plated wound on my leg hadn’t healed since the last surgery, and a bloody plastic drain hung out of a small incision near my hip. It was clear that she had come to deliver bad news, and I braced myself for the onslaught of sensitivity. E(ye contact)!M(uscles of facial expression)!P(osture)! A(ffect)!… She stuck every landing. The judges flashed their scorecards: 10 out of 10.But I wasn’t listening. I focused my eyes on the wall behind her head, conjuring yesterday’s image of jet-black radiotracer diffusing through my lymphatics on screen. Brownian motion, as beautiful in malignancy as in snuffed candle smoke.Her entire performance had been planned before she entered the room, and she executed it to a T. Yet there was nothing about it that felt empathetic. She gave me the sense that had I dressed a fifty-pound sack of feed in a hospital gown and propped it up in bed, the scene would have played out identically. Her manufactured emotion made me lonelier than had she displayed none at all.In contrast, my surgeon was a straight shooter with an unadorned manner who showed me that she cared without having to say so. At one early visit after I deferred a biopsy to go camping in the Blue Ridge Mountains, she walked into the exam room, looked straight at me, and with no preamble said sternly, “I urge you to take this seriously.” She would have received demerits on the Rating Scales for the Assessment of Empathic Communication in Medical Interviews (“Did the physician admonish the patient?”), but the fact that she cared enough to be upset reached me more than any salvo of empathy statements. It was one of the few times that I nearly broke my vow not to cry in front of doctors. Not because I had been scolded, but because I trusted her, and I didn’t want it to be serious enough to take seriously. I stopped ignoring my diagnosis after that.DistanceThese events changed me more than I acknowledged at the time. They brought me into direct contact with indifference. I asked for contact, and I got it. I became a canvas for cellular replication independent of the biological economy of my body. My fascination with the mechanism of lichen acid’s disintegration of stone became experiential rather than intellectual. It is awful and thrilling to feel so much like acted-upon matter. It is like the high after an electric fence shocks you to the bone, or an unprotected blow to the face while sparring. You can’t override instinct enough to seek it out, but you’re not exactly sorry it happened.I needed distance and open terrain to understand what still mattered within uncertain time parameters. I went on the road with my confidant, a hundred-pound juvenile delinquent St. Bernard mutt. He was a kennel flunk-out with scars across his snout from charging the metal grid of his cage. I had trained him with the patience misfits have for their own kind. We drove to northern Canada and spent three months roaming the bluffs. We communicated without speaking for so long that it didn’t sound like silence anymore. I understood the raised hair on his nape or his flared black nostril. In response to my upsloping whistle, he would lope over to sit guard beside me while I napped in peat moss. Downsloping, and he was released to run free, eating shreds of mollusk flesh out of seagulls’ discarded shells.One night after a long hike, heavy sleet iced a winding road overlooking the North Atlantic. My truck bed swayed, and gravel ripped one tire off the shoulder. Burning metal cut the salt air. I formed a single thought: My dog.Afterward, responders crowded in with questions as I stood mute. This continued until an officer called the others off with several succinct gestures and made his way to me. Saying nothing, he wrapped one hand around my rigid arm. I flinched. He did not change the force or position of his grip until he felt my muscle give under the pressure of his hand. One knuckle at a time, he released my fingers from the dog’s brown-on-white fur, refolding each finger into my palm before lifting the next. He wrapped me in his coat, maneuvered me to a vehicle, and laid the dog in my lap. Removing a knife from his pocket, he cut a tuft of my dog’s fur and closed my hand back around it. I will wear this in a locket for the rest of my life.He squeezed my arm more tightly, released it, and closed the door. My eyes clung to him in the rearview mirror. His entire body tensed as he coiled and unwound his arm like a spring into the trunk of the tree the dog had broken its back on. “F-ck!” His voice rang through the window as he leaned his forehead into the tree’s bark.His firm gentleness required no performance. He won my trust without speaking a word. He would have earned poor marks on the empathy scorecard, but he was unmistakably present with me in my hurt.Unteachable EmpathyI rarely choose to disclose personal experiences. I’ve done so here out of a desire to respond to the reductive approaches to human interaction that are ubiquitous in medical education.Researchers cite improved patient ratings of clinical interactions as evidence for the success of empathy interventions. However, in a 2017 study by Martina Wündrich and colleagues, students reported no difference in self-perceived empathy following such an intervention. In short, the students hadn’t changed; the motions through which they were going had. According to the Four Habits Model still championed by some medical educators, clinicians should make empathetic statements such as “That must be difficult for you” at least once every visit. While such rote tactics appear mild compared with the scripting that has been promoted elsewhere in the health sector, such as patient interviews in nursing, they nonetheless leave many trainees with the sense that they have committed a kind of betrayal. As one Japanese student said after an empathy training, “I learned some skills of interviewing patients, but I could not empathize with patients very well; I felt like I had lied when I said emphasizing [sic] words to them” (from “Communication Skills Training and the Conceptual Structure of Empathy among Medical Students,” by Daisuke Son and colleagues).Is empathy even the right goal? A 2009 review in Patient Education and Counseling of nearly forty assessment scales used in research on empathy in medicine provides an overview of self-reported measures (such as the Interpersonal Reactivity Index, Jefferson Scale of Empathy, and Questionnaire Measure of Emotional Empathy), as well as observer-rated tools such as the Accurate Empathy Scale and Roter Interaction Analysis System. These schemas include items such as “I tend to lose control during emergencies,” “I become nervous if others around me seem to be nervous,” and “I am able to remain calm even though those around me worry” (reverse coded). “Susceptibility to emotional contagion” is its own subcategory of the Questionnaire Measure of Emotional Empathy, and it correlates positively with empathy scores. Yet these are not qualities that most would seek to cultivate in young physicians. Scholars have gotten around the issue of overidentification with patients by drawing distinctions between “affective” and “cognitive” empathy, the latter being a form of the trait that permits clinicians to remain in possession of their executive neutrality while also engaging with their patient’s perspective. These issues have been extensively debated in the literature by psychologists, ethicists, and medical educators. In practice, however, the empathy curricula are running at full steam, with too little nuance in their conceptualization and application.Medical trainees have started to question this approach. We must rigorously evaluate how we communicate with patients, but resorting to formulas does not solve the problem. While we are instructed to say, “I can’t imagine how difficult this is for you,” to avoid the presumption implicit in “I can imagine that this is very difficult for you,” asking would be a great place to start: “What is this like for you? What are you going through? Tell me your story.” Open-ended inquiries stop a protocolized approach dead in its tracks and do not feature prominently in empathy instruction. Mired in flowcharts that do not take into account the individuality of the patient sitting before us, we cannot be em- pathos; we are stuck in our own heads. It is not possible to script genuine empathy.In Search Of AuthenticityMy medical school uses a “Keep/Stop/Start” format for feedback (that is, what should we keep, stop, or start doing?). I respond in kind. Keep insisting on the importance of emotional intelligence in medicine. Stop adopting a reductive approach to its inculcation. Start selecting students who are capable of responding to suffering without referring to an instruction manual. Educators could train students to check every box on the empathy rubric, as the doctor at the teaching hospital did. By all metrics, she aced the performance, but in so doing, she alienated me with the contrivance. Or schools could forgo the template and encourage us to be with the patient, as my surgeon and the police officer were. It would be less polished, but the hospital would be a better place.While I don’t have the solution for how to teach the faculty of empathy to individuals who innately lack it, what I ask is that we recomplicate the concept. The importance of the problem demands a more nuanced approach.Ideally, medical schools would select students who possessed these abilities innately. But short of this, what are the options? Just as there is no single script that applies to all patients, there is unlikely to be one right answer. In a 2009 Lancet perspective piece titled “The Dangerous Practice of Empathy,” Jane Macnaughton, director of the Centre for Medical Humanities at Durham University in the UK, wrote that a crucial role of the medical humanities is to keep a critical eye “on the way in which medicine can highjack complex ideas, confining and defining them in its own terms, and changing their meaning and impact.” While I don’t have the solution for how to teach the faculty of empathy to individuals who innately lack it, what I ask is that we recomplicate the concept. The importance of the problem demands a more nuanced approach. Perhaps the “fake it till you make it” school of behavioral change has some credence. But until these rote performances engender genuine empathy in the student, I ask that we call it something different. This may seem like semantics, but it is important. For some patients, simulated empathy may be better than none. I am not one of those patients. Regardless, we should at least be explicit about what we are doing.Pain wants authenticity. As medical trainees we sit with patients who are past consolation, and a stock response is inadequate. Compassion is not a compounding pharmacy. There is no formula for empathy. There is no equation for how to understand an individual patient’s experience of their condition and no script for how to respond in a genuine manner that takes this into account. But by elucidating these as the goals in the face of patient distress, we will achieve something much closer to meaningful presence in their pain.Suffering looks me in the eyes and demands, “Give me something real.” I look straight back. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article MetricsCitations: Crossref 9 History Published online 3 February 2020 Information© 2020 Project HOPE—The People-to-People Health Foundation, Inc.PDF downloadCited bySetting the agenda for health communication research: Topics and methodologiesPatient Education and Counseling, Vol. 106Internal Medicine Residents’ Experience Performing Routine Assessment of What Matters Most to Patients Upon Hospital Admission22 January 2022 | Teaching and Learning in Medicine, Vol. 35, No. 1A Scoping Review on the Concept of Physician Caring7 April 2022 | Journal of General Internal Medicine, Vol. 37, No. 12Challenging the clinically-situated emotion-deficient version of empathy within medicine and medical education research22 November 2021 | Social Theory & Health, Vol. 20, No. 3The different faces of empathy in cancer care: From a desired virtue to an evidence‐based communication process5 August 2021 | Cancer, Vol. 127, No. 22What is clinical empathy? Perspectives of community members, university students, cancer patients, and physiciansPatient Education and Counseling, Vol. 104, No. 5Teaching empathy in an interprofessional setting with a focus on decategorization: Introducing I-TeamJournal of Interprofessional Education & PracticeGhosts in the Exam Room, Empathy, and Physician Well-BeingJournal of Graduate Medical Education, Vol. 12, No. 5Practicing “Reflective listening” is a mandatory prerequisite for empathyPatient Education and Counseling, Vol. 103, No. 9Related articlesThere’s No Algorithm For Empathy18 Feb 2020Default Digital Object Series